Swallowing Exercise During Head and Neck Cancer Treatment: Results of a Randomized Trial

Head and Neck Cancer (HNC) Prehabilitation: Advantages and Limitations

Cancer prehabilitation is the process between the time of cancer diagnosis and the beginning of the active acute treatment; prehabilitation consists of various need-based interventions, e.g., physical activity, a nutritional program, and psychological support. It can be delivered as unimodal or multimodal interventions. Physical activity, including resistant exercise and aerobic activities, has to be tailored according to the patient's characteristics; nutritional support is aimed at preventing malnutrition and sarcopenia; while psychological intervention intercepts the patient's distress and supports specific intervention to address it. In addition, multimodal prehabilitation could have a potential impact on the immune system, globally reducing the inflammatory processes and, as a consequence, influencing cancer progression. However, many challenges are still to be addressed, foremost among them the feasibility of prehabilitation programs, the lack of adequate facilities for these programs' implementation, and the fact that not all prehabilitation interventions are reimbursed by the national health system.

Feasibility of individualized home exercise programs for patients with head and neck cancer-study protocol and first results of a multicentre single-arm intervention trial (OSHO #94)

INTRODUCTION

Patients with head and neck cancer (PwHNC) benefit from targeted exercise interventions: symptom relief, compensation for dysfunction, improvement in quality of life (QoL). Data on acceptance physical interventions in PwHNC are rare. The 'OSHO #94' trial investigates the short- and medium-term effects of individualized home exercise in PwHNC on QoL, physical activity and functionality. The study includes a feasibility phase (proof of concept) in order to evaluate the acceptance. Here we present the study protocol as well as the feasibility results.

METHODS AND ANALYSIS

This prospective, multicentre, single-arm intervention study includes PwHNC ≥18 years of age in aftercare or palliative care with stable remission under immunotherapy. The study opened in January 01, 2021, with estimated completion by December 31, 2024. The PwHNC receive an individualized home exercise program consisting of mobilization, coordination, strengthening and stretching exercises. This should be carried out at least three times a week over 12 weeks for 15 to 30 minutes, supplemented by aerobic training two to three times a week for 30 minutes (intervention). Once weekly telephone calls with a physiotherapist are performed. Subsequently, there is a 12-week follow-up (FU) without exercise specifications/contact. Outcomes are measured before and after the intervention and following the FU. Primary outcome of the feasibility phase (n = 25) was the determination of the dropout rate during the intervention with a termination cut off if more than 30% PwHNC withdrew premature. The primary outcome of the OSHO #94' trial (N = 53) is the change in global QoL score from pre- to post-intervention (EORTC QLQ-C30). Secondary outcomes include clinical and patient-reported measures, training details as well as functional diagnostic data (e.g. level of physical activity, training frequency, flexibility, fall risk and aerobic performance).

RESULTS

25 PwHNC were enrolled onto the feasibility cohort. Only16% (4/25 patients) did not complete the study. Therefore, recruitment of PwHNC was continued. The dropout rate was adjusted from 30% (N = 60) to 20% (N = 53, calculated sample size n = 42 PwHNC and 20% (n = 11) to dropout).

CONCLUSIONS

Individualized home exercise programs in PwHNC in aftercare seem feasible. Consequently, the aim is now to evaluate the short and medium-term effects of individualized home exercise.

Effects of different nutritional support methods on nutritional status and immune function in patients undergoing radiotherapy for head and neck cancer

OBJECTIVE

This study aimed to analyze the effects of different nutritional support methods on nutritional status and immune function of patients undergoing radiotherapy for head and neck cancer (HNC).

METHODS

Patients with HNC were divided into the control (nutritional counseling and routine dietary guidance), parenteral nutrition (PN) (PN support on top of the control group), enteral nutrition (EN) (EN support on top of the control group), and EN + PN (EN combined with PN and routine dietary guidance) groups. After nutrition evaluation, the four groups were subjected to radiotherapy and nutritional support. Body mass index (BMI), serum albumin (ALB), prealbumin (PA), transferrin (TRF), hemoglobin (Hb), CD3+, CD4+, CD8+, CD4+/CD8+, natural killer (NK) and quality of life were compared among the four groups before radiotherapy and after radiotherapy dose irradiation completion. The incidence of adverse reactions was assessed and recorded at 2 weeks, 4 weeks and the end of radiotherapy.

RESULTS

The four groups experienced some degree of malnutrition during radiotherapy and the EN + PN group possessed the lowest degree of malnutrition. After radiotherapy dose irradiation completion (T1), the PN, EN, and EN + PN groups possessed improved BMI (21.42 ± 1.62, 21.40 ± 1.68, 22.98 ± 1.87 vs. 20.18 ± 1.32), serum ALB (31.59 ± 3.49, 32.24 ± 4.23, 37.58 ± 3.23 vs. 26.67 ± 3.03), PA (182.63 ± 13.57, 183.43 ± 14.19, 201.59 ± 10.53 vs. 165.36 ± 20.13), TRF (162.46 ± 24.34, 157.36 ± 18.58, 182.36 ± 20.37 vs. 137.56 ± 23.19), and Hb (128.54 ± 9.21, 125.36 ± 10.23, 140.26 ± 7.23 vs. 103.24 ± 9.47) levels, higher CD3+ (63.59 ± 2.88, 63.25 ± 3.17, 66.54 ± 1.32 vs. 59.36 ± 3.24), CD4+ (39.92 ± 3.16, 39.87 ± 3.23, 43.36 ± 2.87 vs. 37.12 ± 4.29), CD4+/CD8+ (1.80 ± 0.06, 1.78 ± 0.06, 2.07 ± 0.03 vs. 1.54 ± 0.10) and NK-cells (33.87 ± 3.62, 33.26 ± 3.59, 36.82 ± 3.19 vs. 27.36 ± 4.21) levels, lower CD8+ (22.18 ± 1.07, 22.36 ± 1.04, 20.46 ± 1.09 vs. 24.09 ± 1.21) levels, and improved quality of life (79.97 ± 7.96, 80.13 ± 7.98, 91.78 ± 7.38 vs. 71.53 ± 11.70) versus the control group, and the EN + PN group possessed the most pronounced effects (All P < 0.05). During radiotherapy, the incidence of radiotherapy adverse reactions was increased with time (P < 0.05).

CONCLUSION

PN and EN, alone or in combination, can improve the nutritional status, immune function and quality of life of patients undergoing radiotherapy for HNC, and PN combined with EN has the best improvement effect.

Patient management with Head and Neck tumors-A nationwide data collection in oral and maxillofacial surgery

INTRODUCTION

This study analyzed oncologic patient management from initial tumor diagnosis to tumor follow-up in oral and maxillofacial surgery (OMFS) in Germany.

MATERIAL AND METHODS

A dynamic online questionnaire with a total of 44 questions was used to generate general and specific data regarding oncologic patient management with head and neck malignancies, supportive care, and (pre-) rehabilitation from initial tumor diagnosis to tumor follow-up and head and neck cancer center (HNCC) structures in OMFS in Germany. The questionnaire was sent to 81 OMFS departments affiliated with the German-Austrian-Swiss Working Group for Tumors of the Jaw and Facial Region (DÖSAK) and the German Association of Oral and Maxillofacial Surgery (DGMKG). Data analysis was conducted descriptively.

RESULTS

Forty-eight OMFS departments participated (response rate 59.26%), of which 36/48 (75%) were certified HNCC. 28/34 (82.4%) reported subjective improvements in oncologic care, most often interdisciplinary collaboration (21/33, 63.64%) and clinic structure changes (21/34, 61.76%). Nearly all OMFS departments present patients in multidisciplinary tumor boards (45/46, 97.83%) and aim for osseous reconstruction post-tumor resection (43/44, 97.73%). Significant discrepancies regarding the frequency of masticatory-functional dental rehabilitation following osseous reconstruction were observed. Before oncologic therapy, patients are offered various supportive services, mostly psychotherapy and psycho-oncological support (24/26, 92.31%). Post-therapy, speech therapy (43/43, 100%), physiotherapy (40/43, 93.02%), lymphatic drainage, and follow-up rehabilitation (39/43, 90.7%, respectively) are most often offered. 17/43 (39.53%) have oncological nursing staff. 36/40 (90%) manage patients and side effects during adjuvant therapy, while 5/41 (12.2%) provide proprietary palliative care. 36/41 (87.8%) offer counseling to patients and families.

CONCLUSION

Oncologic patient care in OMFS is highly standardized and potentially attributable to many certified HNCCs in Germany. Certain treatment aspects are handled differently, possibly due to institution-specific reasons.

CLINICAL RELEVANCE

The high homogeneity in treatment protocols reflects the widespread high and comparable treatment quality of head and neck malignancies in OMFS in Germany.

Treatment of elderly patients with head and neck cancer in an aging society: Focus on geriatric assessment and surgical treatment

Previous studies of the treatment of elderly head and neck cancer (HNC) patients were very limited and sometimes controversial. Although conclusions differ across various reports, it is often concluded that advanced chronological age does not directly affect prognosis, but that comorbidities and declines in physical and cognitive functions promote the occurrence of adverse events, especially with surgical treatment. Geriatric assessment (GA) and its screening tools are keys to help us understand overall health status and problems, predict life expectancy and treatment tolerance, and to influence treatment choices and interventions to improve treatment compliance. In addition, personal beliefs and values play a large role in determining policies for HNC treatment for elderly patients, and a multidisciplinary approach is important to support this. In this review, past research on HNC in older adults is presented, and the current evidence is explained, focusing on the management of elderly HNC patients, with an emphasis on the existing reports on each treatment stage and modality, especially the surgical procedures.

Dysphagia in Head and Neck Cancer

Dysphagia is a common symptom in patients with head and neck cancer that can significantly impact health outcomes and quality of life. The origin of dysphagia in these patients is often multifactorial, making diagnosis and management especially complex. The evaluating otolaryngologist should be well versed with the patient's neoplasm, comorbidities, and treatment history alongside dysphagia-specific imaging modalities. Management is often dynamic, requiring frequent monitoring, interprofessional collaboration, and a variety of supportive and invasive measures to achieve optimal outcomes.

Preventing radiation-induced dysphagia and trismus in head and neck cancer-A randomized controlled trial

BACKGROUND

Radiation-induced dysphagia and restricted mouth opening are common problems among patients with head and neck cancer. The aim of the present randomized controlled trial was to determine if an exercise protocol could prevent swallowing and mouth opening impairment.

METHODS

Eighty-nine participants were randomly assigned to either an active group performing preventive swallowing and mouth opening exercises (n = 45) or to a control group (n = 44). Outcome measures were collected at baseline before radiotherapy and approximately 1-month post-treatment. Primary endpoints were changes in swallowing function according to the Penetration Aspiration Scale and mouth opening ability measured in millimeters. Intention-to-treat analysis was used.

RESULTS

Swallowing function and mouth opening deteriorated in both groups, with no statistically significant positive effect of the protocol detected at follow-up. Among patients who completed >75% of exercises, there was a trend toward better outcomes.

CONCLUSIONS

Preventive exercises did not improve short-term swallowing function and mouth opening after radiotherapy.

Effect of nonpharmacological interventions on nutrition status, complications and quality of life in head and neck cancer patients undergoing radiotherapy: A systematic review and meta-analysis

PURPOSE

To evaluate the effect of nonpharmacological therapies on nutrition status, complications and quality of life in head and neck cancer patients and to provide a basis for clinical practice.

METHODS

This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Ten databases were systematically searched for all available articles from construction to November 2023. Two researchers independently conducted literature screening, data extraction and quality evaluation. Cochrane Review Manager 5.3 was used for meta-analysis.

RESULTS

Finally, 27 RCT studies including 2814 patients with head and neck cancer were included. Five categories of interventions were used: nutritional support, exercise, swallowing function training, psychological intervention and low-level laser therapy. Nonpharmacological interventions can improve body weight loss in patients with HNC at the end of treatment (MD: 1.66 kg; 95% CI: 0.80 to 2.51), and subgroup analysis showed that nutritional support, psychological intervention and low-level laser therapy were effective. Nonpharmacological interventions can also ameliorate decreases in BMI (MD: 0.71; 95% CI: 0.16 to 1.26) and reduce the incidence of malnutrition (RR: 0.76; 95% CI: 0.67 to 0.86), oral mucositis (RR: 0.54; 95% CI: 0.37 to 0.80) and gastrointestinal complications (RR: 0.61; 95% CI: 0.38 to 0.96) during radiotherapy; however, no significant differences were found in other complications and quality of life.

CONCLUSION

Nonpharmacological interventions can improve the nutrition status of patients with head and neck cancer and reduce the incidence of severe oral mucositis and gastrointestinal complications during radiotherapy but have no significant impact on quality of life.

Exploring the use of rehabilitation in individuals with head and neck cancer undergoing treatment: a scoping review

Explore the use, characteristics, feasibility, and functional outcomes of rehabilitation interventions used for individuals with head and neck cancer (HNC) during treatment.

Searches were conducted in four databases from Jan 2011 to Dec 31, 2022. Included studies had to include adults with HNC undergoing treatment, a rehabilitation intervention, an assessment of functional outcome(s) addressed by the International Classification of Functioning Framework (ICF) and be published in English language. Title and abstract screening, full-text review, and data extraction were completed independently, in duplicate. Descriptive statistics and a qualitative synthesis summarized findings.

Twenty-seven studies were included in this review. The majority of studies were randomized controlled trials (70%). Most individuals represented in the included studies were males (92% of all participants) between 50 and 60 years of age. Interventions led by a speech language pathologist (33%) were most commonly described. Sixteen studies (59%) described primary outcomes that fit the ICF "impairment" domain.

We identified few studies that explored the use, feasibility, and effectiveness of rehabilitation interventions for individuals with HNC during treatment. Future research should assess the effectiveness of rehabilitation interventions on functional outcomes beyond the ICF body function and structure domain.

Rehabilitation Interventions in Head and Neck Cancer: A Scoping Review

OBJECTIVE

The aim of the study is to identify and appraise current evidence for rehabilitation interventions in head and neck cancer.

DESIGN

A previously published scoping review spanning 1990 through April 2017 was updated through January 11, 2023 and narrowed to include only interventional studies (Arch Phys Med Rehabil. 2019;100(12):2381-2388). Included studies had a majority head and neck cancer population and rehabilitation-specific interventions. Pairs of authors extracted data and evaluated study quality using the PEDro tool. Results were organized by intervention type.

RESULTS

Of 1338 unique citations, 83 studies with 87 citations met inclusion criteria. The median study sample size was 49 (range = 9-399). The most common interventions focused on swallow (16 studies), jaw (11), or both (6), followed by whole-body exercise (14) and voice (10). Most interventions took place in the outpatient setting (77) and were restorative in intent (65 articles). The overall study quality was fair (median PEDro score 5, range 0-8); none were of excellent quality (PEDro >9).

CONCLUSIONS

Most head and neck cancer rehabilitation interventions have focused on restorative swallow and jaw exercises and whole-body exercise to address dysphagia, trismus, and deconditioning. More high-quality evidence for head and neck cancer rehabilitation interventions that address a wider range of impairments and activity and social participation limitations during various cancer care phases is urgently needed to reduce head and neck cancer-associated morbidity.

Pre-rehabilitation interventions for patients with head and neck cancers: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of pre-rehabilitation interventions such as nutrition and exercise for patients with head and neck cancer (HNC).

METHODS

Web of Science, PubMed, Scopus, Google Scholar, and Cochrane databases were searched up to December 2022. Quality of life, length of hospital stay, postoperative complications, change in body mass index or muscle mass, and functional assessments were the primary outcomes. PRISMA guidelines were adhered to, and the study was registered on PROSPERO. The Cochrane Collaboration tool and Newcastle Ottawa scale assessed the quality of included studies. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan5.4.

RESULTS

A total of 31 articles were included for quantitative analysis and 15 for qualitative synthesis. Nutrition alone resulted in significant weight retention (2.60; 2.32, 2.88, p < 0.00001), length of stay (-4.00; -6.87, -1.13), p = 0.0006) and complications (0.64; 0.49, 0.83, p = 0.0009). Nutrition and psychoeducation resulted in a significant reduction in mortality rate (0.70; 0.49, 1.00, p = 0.05 and 0.60; 0.48, 0.74, p < 0.00001), and exercise resulted in a significant reduction in dysphagia (0.55; 0.35, 0.87, p = 0.01). Exercise with nutrition resulted in significant improvements in weight loss, length of stay, complications, and dysphagia. Randomized controlled trials (RCTs) had a moderate risk of bias and cohort studies were of fair to good quality.

CONCLUSION

Prehabilitation programs based on exercise, nutrition, or psychoeducation demonstrated improved post-interventional outcomes in HNC, such as quality of life, and mortality and morbidity. Studies with longer follow-ups and larger sample sizes, and investigations comparing nutritional supplements with exercise programs are needed.

Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation

Background

Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy.

Methods

A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2.

Results

Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups.

Discussion

Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed.

Other

There was no funding and no registration.

Interventions to improve quality of life in patients with head and neck cancers receiving radiation therapy: a scoping review

BACKGROUND

Quality of life (QOL) is impaired in patients with head and neck cancers (HNC) due to illness and treatment-associated morbidity. Although there is evidence from the studies on interventions' role in improving QOL receiving radiation therapy, these are not systematically synthesised. In this scoping review, we searched and synthesised the evidence on interventions to improve the QOL and its impact among patients with HNCs.

METHODS

This scoping review was conducted using the framework proposed by Arksey and O'Malley, and the extensions suggested by Levac et al. were incorporated. Two reviewers independently searched four electronic databases using key thesaurus and free-text terms, and the data was extracted, tabulated, synthesised and reported as categories.

RESULTS

Seventy-nine papers reported various interventions of diverse nature such as pharmacological, physical, nutritional, complementary and alternative therapies, psychosocial, oral care related, laser and photobiomodulation therapies, rehabilitative, educational, technology-based, surgical, device-related and nurse lead interventions. Most studies reported clinically meaningful impact of interventions on QOL, although the outcome differences were often statistically insignificant. Few studies reported a combination of interventions to address the multidimensional concerns faced by patients with HNCs. None of the studies examined the impact of interventions on QOL among long-term survivors of HNCs.

CONCLUSION

As QOL concerns in patients with HNCs are multifaceted, more extensive studies with complex multi-component interventions and robust research designs are warranted.

A randomized controlled study evaluating the head-lift exercise in head and neck cancer patients with radiation-induced dysphagia: effect on swallowing function and health-related quality of life over 12 months

PURPOSE

Dysphagia is common after radiotherapy for head and neck cancer (HNC) and can affect health-related quality of life (HRQL). This randomized controlled trial aimed to evaluate the effect of the head-lift exercise (HLE) over 12 months in HNC patients with radiation-induced dysphagia.

METHODS

Sixty-one patients with dysphagia were randomized to intervention group (n = 30) and control group (n = 31) at 6-36 months after completion of radiotherapy for HNC. Dysphagia-specific HRQL was measured with the MD Anderson Dysphagia Inventory (MDADI); general and HNC-specific HRQL was measured with the European Organization for Research and Treatment of Cancer Quality of Life questionnaire Core 30 (EORTC QLQ-C30) and QLQ-H&N35. Measurements were made at baseline, and at 8 weeks and 12 months after start of intervention.

RESULTS

Adherence to the intervention was good throughout the year. When comparing change from baseline reports to each follow-up no statistically significant differences between the groups were found in any of the HRQL instruments. There were some statistically significant changes within groups compared to baseline. The intervention group improved self-rated swallowing function on the MDADI at 8 weeks (emotional domain, p = 0.03; functional domain, p = 0.007; total score, p = 0.01) and the control at twelve months (emotional domain, p = 0.03; functional domain, p = 0.02; physical domain, p = 0.004; total score, p = 0.002).

CONCLUSION

In this randomized control study, no effect was observed short term or at 12 months on HRQL after use of the HLE as rehabilitation for radiation-induced dysphagia.

Effectiveness of Home-Based Telerehabilitation Interventions for Dysphagia in Patients With Head and Neck Cancer: Systematic Review

BACKGROUND

Multimodal treatment-induced dysphagia has serious negative effects on survivors of head and neck cancer. Owing to advances in communication technologies, several studies have applied telecommunication-based interventions that incorporate swallowing exercises, education, monitoring, feedback, self-management, and communication. It is especially urgent to implement home-based remote rehabilitation in the context of the COVID-19 pandemic. However, the optimal strategy and effectiveness of remote interventions are unclear.

OBJECTIVE

This systematic review aimed to examine the evidence regarding the efficacy of telerehabilitation for reducing physiological and functional impairments related to swallowing and for improving adherence and related influencing factors among head and neck cancer survivors.

METHODS

The PubMed, MEDLINE, CINAHL, Embase, and Cochrane Library databases were systematically searched up to July 2023 to identify relevant articles. In total, 2 investigators independently extracted the data and assessed the methodological quality of the included studies using the quality assessment tool of the Joanna Briggs Institute.

RESULTS

A total of 1465 articles were initially identified; ultimately, 13 (0.89%) were included in the systematic review. The quality assessment indicated that the included studies were of moderate to good quality. The results showed that home-based telerehabilitation improved the safety of swallowing and oral feeding, nutritional status, and swallowing-related quality of life; reduced negative emotions; improved swallowing rehabilitation adherence; was rated by participants as highly satisfactory and supportive; and was cost-effective. In addition, this review investigated factors that influenced the efficacy of telerehabilitation, which included striking a balance among swallowing training strategy, intensity, frequency, duration, and individual motor ability; treating side effects of radiotherapy; providing access to medical, motivational, and educational information; providing feedback on training; providing communication and support from speech pathologists, families, and other survivors; and addressing technical problems.

CONCLUSIONS

Home-based telerehabilitation has shown great potential in reducing the safety risks of swallowing and oral feeding, improving quality of life and adherence, and meeting information needs for dysphagia among survivors of head and neck cancer. However, this review highlights limitations in the current literature, and the current research is in its infancy. In addition, owing to the diversity of patient sociodemographic, medical, physiological and functional swallowing, and behavioral factors, we recommend the development of tailored telemedicine interventions to achieve the best rehabilitation effects with the fewest and most precise interventions.

[Patient-reported outcomes in head and neck cancer treatment: relevance, challenges, and benefit]

Next to overall survival, quality of life is becoming more and more pivotal for cancer patients. The various domains of quality of life are complex and have different value to each patient. However, not only patients but also health care professionals, the pharmaceutical industry, and regulatory bodies ask: How can quality of life be reliably ascertained in clinical trials? For this purpose, carefully developed and validated specific questionnaires are needed: the patient-reported outcome measures (PROMs). A key challenge is to define how results based on PROMs can be used for shared decision-making. Next to clinical factors such as health and nutritional status, quality of life acts as a prognostic factor for overall survival in cancer. Thus, it is crucial to take quality of life into account in daily clinical practice.

Exercise-based rehabilitation on functionality and quality of life in head and neck cancer survivors. A systematic review and meta-analysis

Head and Neck Cancer (HNC) is a globally rare cancer that includes a variety of tumors affecting the upper aerodigestive tract. It presents with difficulty breathing or swallowing and is mainly treated with radiation therapy, chemotherapy, or surgery for tumors that have spread locally or throughout the body. Alternatively, exercise can be used during cancer treatment to improve function, including pain relief, increase range of motion and muscle strength, and reduce cancer-related fatigue, thereby enhancing quality of life. Although existing evidence suggests the adjunctive use of exercise in other cancer types, no previous studies have examined the effects on HNC survivors. The aim of this meta-analysis was to quantify the effect of exercise-based rehabilitation on functionality and quality of life in HNC survivors who underwent surgery and/or chemoradiotherapy. A systematic review and meta-analysis were carried out following PRISMA statement and registered in PROSPERO (CRD42023390300). The search was performed in MEDLINE (PubMED), Cochrane Library, CINAHL and Web of Science (WOS) databases from inception to 31st December 2022 using the terms "cancer", "head and neck neoplasms", "exercise", "rehabilitation", "complications", "muscle contraction", "muscle stretching exercises" combining with booleans "AND"/"OR". PEDro scale, Cochrane Risk of Bias Tool and GRADE were used to assess methodological quality, risk of bias and grade of recommendation of included studies respectively. 18 studies (n = 1322) were finally included which 1039 (78.6%) were men and 283 (21.4%) were women. In patients who underwent radio-chemotherapy, overall pain [SMD = - 0.62 [- 4.07, 2.83] CI 95%, Z = 0.35, p = 0.72] and OP [SMD = - 0.07 [- 0.62, 0.48] CI 95%, Z = 0.25, p = 0.81] were slightly reduced with exercise in comparison to controls. Besides, lower limb muscle strength [SMD = - 0.10 [- 1.52, 1.32] CI 95%, Z = 0.14, p = 0.89] and fatigue [SMD = - 0.51 [- 0.97, - 0.057] CI 95%, Z = 2.15, p < 0.01] were also improved in those who receive radio-chemoradiation. In HNC survivors treated with neck dissection surgery, exercise was superior to controls in overall pain [SMD = - 1.04 [- 3.31, 1.23] CI 95%, Z = 0.90, p = 0.37] and, in mid-term, on shoulder pain SMD = - 2.81 [- 7.06, 1.43] CI 95%, Z = 1.76, p = 0.08]. No differences in quality of life were found at any of the follow-up periods. There is evidence of fair to good methodological quality, low to moderate risk of bias, and weak recommendations supporting the use of exercise-based rehabilitation to increase functionality. However, no evidence was found in favor of the use of this modality for improving the quality of life of HNC survivors who underwent chemoradiotherapy or surgery.

Dysphagia Advances in Head and Neck Cancer

Purpose of Review

This review summarises the current literature regarding head and neck cancer-associated dysphagia. Up-to-date evidence for dysphagia outcome measurement for this population is provided, in addition to recent innovations that aim to prevent, reduce or remediate the common and debilitating side effects of treatment.

Recent Findings

Both patient-reported outcomes and clinical measures are necessary to capture the multi-dimensional nature of swallowing. A minimally important difference in scores has been calculated for some of these measures, to aid interpretation and powering of clinical trials. The number of dysphagia-related trials has increased, predominantly investigating optimal treatment for oropharyngeal HPV-positive disease, and speech and language pathology interventions using an impairment-based approach.

Summary

Although substantial progress has been made, further work is necessary to establish a consensus over outcome measures. Modifying treatments may improve outcomes. Several trials are underway to establish the effectiveness of speech and language pathology dysphagia interventions.

The use and effects of whole-body exercises on swallowing function: A scoping review

BACKGROUND

Swallowing function can become impaired due to primary medical conditions or age-related presbyphagia, resulting in swallowing disorders, known as dysphagia. Specific manoeuvres that target different musculature have been innovated and researched, but whole-body exercises (WBE) that target multiple large groups of body systems and muscles have been rarely considered in dysphagia management, despite the causes of dysphagia being often systemic.

AIMS

To identify intervention studies that have used or incorporated WBE to target swallowing function in humans, and report on their findings.

METHODS & PROCEDURES

A scoping review was conducted given the paucity and novelty of this topic in research and practice. Key search terms were used to search five major databases on for all human studies published before 28 November 2022. Studies that were not interventional or used animal models were excluded. All swallowing and oromotor-related outcomes were extracted from the studies. Two researchers independently reviewed all search results following the PRISMA-ScR guideline before meeting to resolve any disagreements.

MAIN CONTRIBUTION

Final analysis was conducted on 11 papers that described 10 studies, with 10 papers (9 studies) reporting positive findings for swallowing or oromotor function-related outcomes. Studies ranged from randomised controlled trials to case studies in design. The study design and populations were heterogeneous, with outcome measures for swallowing and oromotor function ranging from subjective questionnaires to instrumental assessments.

CONCLUSIONS & IMPLICATIONS

Dysphagia rehabilitation that incorporates WBE as part of a comprehensive programme appears to be more beneficial than either WBE or swallowing-related interventions alone. This review is an initial attempt to systematically examine the evidence on this topic. There is a need for future research to study how WBE can be used, either alone or combined with traditional swallowing exercises, to influence swallowing function in different healthy and clinical populations.

WHAT THIS PAPER ADDS

What is already known on this subject Dysphagia rehabilitation usually focuses only on the swallowing muscles and structures of the head, neck, and respiratory system. Whole-body exercise (WBE) and fitness are associated with stronger performance of the tongue muscles, there may be transference potential of WBE to swallowing function. What this paper adds to existing knowledge This review found 10 studies conducted in the last decade that investigated the inclusion of WBE in programmes intended to improve swallowing and/or oromotor-related outcomes. The studies varied widely in design and methodology, but most reported evidence in support of the inclusion of WBE to improve or maintain swallowing and/or oromotor-related functions. What are the potential or actual clinical implications of this work? There is potential for WBE to have a synergistic effect on swallowing function when combined with traditional swallowing exercises. Future clinical research should compare different rehabilitation approaches with controls. Clinicians should enlist allied health professionals who can provide whole-body rehabilitation when managing dysphagia.

Health Literacy and Adherence to Clinical Recommendations in Head and Neck Cancer

BACKGROUND

After definitive cancer treatment, survivors of head and neck cancer (HNC) are commonly recommended to participate in therapies aimed at reducing the burden of treatment-related side effects.

OBJECTIVE

In this study, we evaluated whether adherence to referral to physical therapy (PT) and speech-language pathology therapy (SLPT) is related to patient health literacy (HL).

METHODS

This is a retrospective cohort analysis of patients attending a multidisciplinary HNC survivorship clinic between 2017 and 2019. HL was measured using the Brief Health Literacy Screen, with scores below 10 indicating inadequate HL. Chi-square and logistic regression were used to evaluate the association between HL and adherence to PT or SLPT referral.

KEY RESULTS

From the overall cohort (N = 454), 80 patients (18%) had inadequate HL. Compared to those with adequate HL, patients with inadequate HL were significantly less likely to complete initial PT evaluation (74% vs. 58%, p = .034) but were not significantly less likely to complete initial SLPT evaluation (70% vs. 61%, p = .37). After adjusting for age, primary tumor site, and treatment stage, we found that patients with inadequate HL were half as likely to follow up for initial PT evaluation (odds ratio 0.45, p = .032).

CONCLUSION

Overall, inadequate HL is associated with reduced adherence to PT but is not associated with adherence to SLPT among HNC survivors. These results highlight the clinical importance of HL and underscore the need for interventions to facilitate adherence to treatment for patients with inadequate HL. [HLRP: Health Literacy Research and Practice. 2023;7(1):e52-e60.].

Treatment with head-lift exercise in head and neck cancer patients with dysphagia: results from a randomized, controlled trial with flexible endoscopic evaluation of swallowing (FEES)

BACKGROUND

This randomized study aimed to evaluate the effects of the Shaker head-lift exercise (HLE) to improve dysphagia following oncologic treatment for head and neck cancer (HNC).

METHODS

Patients with dysphagia following oncologic treatment for HNC were randomly assigned to intervention (n = 23) or control (standard dysphagia management, n = 24) groups. Swallowing was evaluated at baseline and at 8-week follow-up using flexible endoscopic evaluation of swallowing (FEES) and self-perceived swallowing with the Eating Assessment Tool (EAT-10). Analysis was performed regarding secretion, initiation of swallow, residue after swallowing, and penetration/aspiration.

RESULTS

Few statistically significant differences were found in the FEES analysis. Some improvement of self-perceived swallowing function was found in both groups. Adherence to training was high.

CONCLUSIONS

This randomized study regarding the effect of the HLE demonstrated that swallowing outcome measures used in assessment of FEES did not improve in patients treated with radiotherapy for patients with dysphagia following HNC.

Quality of Life as a Mediator between Cancer Stage and Long-Term Mortality in Nasopharyngeal Cancer Patients Treated with Intensity-Modulated Radiotherapy

Simple Summary

Even after the implementation of intensity-modulated radiotherapy (IMRT), nasopharyngeal cancer (NPC) survivors may continue to exhibit several physical symptoms that negatively affect long-term quality of life (QoL). An NPC patient cohort study (n = 682) was conducted to examine the potential mediating effect of QoL (evaluated at multiple treatment-related time points) on the cancer stage–mortality association. Patients with advanced NPC exhibited low global health QoL and high QoL-HN35 symptom pre-IMRT, 3 months post-IMRT, and 2 years post-IMRT. Global health QoL and QoL-HN35 symptom scores 2 years after IMRT explained 49.4% and 39.4% of the excessive effect of advanced NPC on mortality risk. Our findings indicate that global health QoL and QoL-HN35 symptom 2 years after IMRT are key mediators of the relationship between advanced NPC and high mortality. These findings emphasize the significance of QoL-HN35 symptom and global health QoL-associated medical support and care for patients with NPC who received IMRT.

Abstract

Background: Quality of life (QoL) attained before, during, or after treatments is recognized as a vital factor associated with therapeutic benefits in cancer patients. This nasopharyngeal cancer (NPC) patient longitudinal study assessed the relationship among QoL, cancer stage, and long-term mortality in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT). Patients and Methods: The European Organization for Research and Treatment of Cancer (EORTC) core QoL questionnaire (QLQ-C30) and the head and neck cancer-specific QoL questionnaire module (QLQ-HN35) were employed to evaluate four-dimensional QoL outcomes at five time points: pre- (n = 682), during (around 40 Gy) (n = 675), 3 months (n = 640), 1 year (n = 578) and 2 years post-IMRT (n = 505), respectively, for 682 newly diagnosed NPC patients treated between 2003 and 2017 at a single institute. The median followed-up time was 7.5 years, ranging from 0.3 to 16.1 years. Generalized estimating equations, multivariable proportional hazards models, and Baron and Kenny’s method were used to assess the investigated effects. Results: Advanced AJCC stage (III–IV) patients revealed a 2.26-fold (95% CI—1.56 to 3.27) higher covariate-adjusted mortality risk than early-stage (I–II) patients. Compared with during IMRT, advanced-stage patients had a significantly low global health QoL and a significantly high QoL-HN35 symptom by a large magnitude at pre-, 3 months, and 2 years post-IMRT. QoL scales at pre-IMRT, 1 year, and 2 years post-IMRT were significantly associated with mortality. The effect changes of mortality risk explained by global health QoL, QoL-C30, and QoL-HN35 symptom were 5.8–9.8% at pre-IMRT but at 2 years post-IMRT were 39.4–49.4% by global health QoL and QoL-HN35 symptoms. Conclusions: We concluded advanced cancer stage correlates with a long-term high mortality in NPC patients treated with IMRT and the association is partially intermediated by QoL at pre-IMRT and 2 years post-IMRT. Therefore, QoL-HN35 symptom and global health QoL-dependent medical support and care should be focused and tailored at 2 years post-IMRT.

Review of prophylactic swallowing interventions for head and neck cancer

BACKGROUND

Head and neck cancer treatment destroys nerves and/or organs associated with swallowing. Previous studies have investigated the efficacy of exercises for muscles used in swallowing before treatment in reducing disuse atrophy and delaying the occurrence of muscle fibrosis. However, the rehabilitation effects of training and the optimal intervention strategy are unknown.

OBJECTIVES

To establish evidence for the efficacy of prophylactic swallowing interventions in reducing aspiration and restoring oral intake in patients with head and neck cancer with dysphagia.

METHODS

We searched electronic databases (PubMed, Embase, Cochrane and MEDLINE) for studies published up to June 2021 reporting outcomes following prophylactic swallowing interventions in patients with head and neck cancer with dysphagia and the related influencing factors. The methodological quality of the literature was assessed using the Joanna Briggs Institute appraisal tools.

RESULTS

The search identified 1468 articles, and 13 studies were eventually included. Four categories involving 12 different swallowing interventions were classified. Regarding the descriptive analysis of the rehabilitation effects across all studies, in terms of oropharyngeal safety, five studies showed that swallowing interventions reduced the risk of aspiration, penetration or residue. In terms of oral intake and tube feeding dependence, four studies demonstrated reduced time to return to oral intake in the intervention group compared with the control group. In terms of intervention adherence, three studies showed that speech-language pathologist- and nurse-supervised training was a potential promoter of adherence, and five studies showed that the negative factors affecting adherence included pain, fatigue, forgetting, smoking, decreased exercise motivation, side effects of radiotherapy and distance to the rehabilitation site.

CONCLUSIONS

Preventive swallowing interventions may be effective at reducing aspiration, improving swallowing function, and restoring oral intake. However, due to the lack of standardization and consistency of interventions and measurement results, which prevented the production of a best practice guide, future rigorous methodological trials will be needed to determine the most effective interventions for maximizing exercise adherence over the long term.